Every finding on record at Denison Nursing and Rehab

Based on observation, record review and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 4 of 5 resident (Resident #1, Resident #2, Resident #3 and Resident #4), reviewed environment. 1. The facility failed to ensure Resident #1's restroom was free from dirty towels and clean on 08/18/26. 2. The facility failed to ensure Resident #1, Resident #2, Resident #3 and Resident #4 had hot water in their restroom sinks on 08/18/26. 3. The facility failed to ensure Resident #3 and Resident #4's shared restroom had baseboards affixed and in good condition on 08/18/26. 4. The facility failed to ensure Resident #3's bedroom had no holes in the wall or electrical wires hanging out of the wall on 08/18/26. These failures could place residents at risk of exposure to infectious diseases, other unsanitary health hazards and affect their sense of dignity. Findings included: Record review of Maintenance Request form dated 1/23/26 revealed Resident #3's toilet and sink were clogged. Record review of Maintenance Request form dated 4/16/26 revealed Resident #1's toilet was clogged. Record review of Maintenance Request form dated 4/28/26 revealed Resident #3's roommate's bed kept coming unplugged. Record review of Resident #1's face sheet dated 8/18/26 reflected a [AGE] year-old male resident with an admission date of 4/6/26. Resident #1 had the following pertinent diagnoses: Major Depressive Disorder (a condition characterized by a persistent feeling of sadness and loss of interest in activities once enjoyed), allergic rhinitis due to pollen ( an immune system reaction that inflames the inside of the nose) and unspecified combined systolic and diastolic heart failure (problems with the heart when it contracts and when it relaxes). Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1's cognition was intact with a BIMS score of 15. An interview and observation of Resident #1 on 8/18/26 at 9:42 a.m. revealed Resident #1's restroom was observed dirty with brown water and paper towels in the toilet, there was also a dirty towel on the floor and the floor brown stains. Resident #1 stated he did not use the restroom because he was incontinent but stated he shared the restroom with another resident and the facility staff had to move the other resident because the toilet in the restroom kept leaking. Record review of Resident #2's face sheet dated 8/18/26 reflected a [AGE] year-old male resident with an admission date of 5/20/26. Resident #2 had the following pertinent diagnoses: chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it hard to breath), unspecified atrial fibrillation (a lung disease that blocks airflow and makes it hard to breathe), acute kidney failure (the sudden loss of kidney function) and muscle wasting. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] reflected Resident #2 was moderately cognitively impaired with a BIMS score of 10. An interview and observation of Resident #2 on 8/18/26 at 9:51 a.m. revealed he used his restroom daily. Resident #2 stated the water in his restroom sink was not hot, but he used it anyways. Resident #2 stated he had mentioned to staff the issue with the hot water but they had not repaired it. Record review of Resident #3's face sheet dated 8/18/26 reflected a [AGE] year-old male resident with an admission date of 2/25/25. Resident #3 had the following pertinent diagnoses: Type 2 Diabetes (a condition in which the body cannot use insulin properly and/or does not make enough insulin), Osteomyelitis (an infection and inflammation of the bone and bone marrow), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and makes it hard to breath) and chronic diastolic heart failure (problems with the heart when it relaxes). Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3's cognition was intact with a BIMS score of 15. An interview and observation with Resident #3 on 08/18/26 9:57 a.m. revealed he had trouble answering questions. Resident #3 would not answer questions related to his room or restroom. Resident #3's restroom was observed with baseboards behind the toilet falling off and the sink had no hot water. Observation of Resident #3's room revealed, on the north wall away from Resident #3's bed, a hole with electrical wiring and outlet hanging from the middle of the wall. Record review of Resident #4's face sheet dated 8/18/26 reflected a [AGE] year-old male resident with an admission date of 5/24/26. Resident #4 had the following pertinent diagnoses: fluid overload, heart failure (when the heart muscle cannot pump blood as it should), acute pulmonary edema (when fluid suddenly builds up in the air sacs of the lungs), acute kidney failure (the sudden loss of kidney function), intermittent explosive disorder (a mental health condition marked by sudden, repeated episodes of extreme anger, verbal [NAME] or physical aggression that are far too intense for the situation) and over active bladder. Record review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 cognition was intact with a BIMS score of 15. Interview and observation with Resident #4 on 8/18/26 at 10:00 a.m. revealed he shared a restroom with Resident #3. Resident #4 stated he struggled to use the toilet in his restroom due to the size of the restroom but used the sink daily. Resident #4 stated the restroom and the whole building were in poor condition and not well maintained. Resident #4 stated the restroom sink had no hot water. Resident #4 stated he used the sink daily because he washed his hands after using his bedside commode. Resident #4 stated the baseboards in his restrooms had been falling off for months. Resident #4 stated he had talked to the staff about the issues with the water and baseboards, but nothing had been done. An interview with EVS Specialist A on 08/18/26 at 10:21 a.m. revealed he cleaned resident's restrooms and rooms every day. EVS Specialist A stated he did not clean Resident #1's restroom daily because Resident #1 did not use his restroom. EVS Specialist A stated that last time he cleaned Resident #1's restroom was when the room next door to Resident #1 was occupied a few weeks ago. EVS Specialist A was shown the conditions of the restroom in Resident #1's room and he stated he was not aware it was dirty and did not know why it would be dirty since Resident #1 did not use his restroom. EVS Specialist A stated he did not clean empty rooms or restrooms because the priority was occupied rooms. EVS Specialist A stated the risk to the residents of not having a clean restroom was the resident could have felt uncomfortable and unhappy. An interview with EVS Specialist B on 08/18/26 at 10:30am revealed he cleaned resident rooms and restrooms daily. EVS Specialist B stated he had not cleaned Resident #1's restroom since the other resident in the room next door was there. EVS Specialist B stated the other resident next door to resident #1 left about a week ago. EVS Specialist B stated Resident #1 did not use his restroom and therefore he did not clean it daily. EVS Specialist B observed the conditions of Resident #1's restroom and stated he was not aware the toilet was dirty and did not know what was inside the toilet. EVS Specialist B stated it was unsanitary for the residents to have a dirty toilet and it was their right to have a clean toilet. An interview with the Housekeeping Supervisor on 8/18/26 at 10:38 a.m. revealed the expectation was all resident rooms and restrooms be cleaned daily except for the empty rooms those should be cleaned every other day. The Housekeeping Supervisor stated Resident #1's restroom should have been cleaned every other day. The Housekeeping Supervisor observed the condition of Resident #1's restroom and she stated it had been brought to her attention earlier that morning that the toilet was dirty with paper towels in it. The Housekeeping Supervisor stated they believed a night CNA had been emptying the bedside commode of another resident in the toilet, but she did not know for sure. The Housekeeping Supervisor stated she had already started in-servicing staff on proper disposal of the bedside commodes, infection control, resident rights and cross contamination. The Housekeeping Supervisor stated towels on the floor in Resident #1's restroom was because the seal ring on his toilet was broken, they had put towels around the toilets until maintenance could fix it. The Housekeeping Supervisor stated the Maintenance Director had gotten terminated over a year ago and the Interim Maintenance Director was supposed to have come to fix it for several weeks but had not. The Housekeeping Supervisor stated the dirty commode, and restroom could affect Resident #1's comfort in his room and his rights. The Housekeeping Supervisor stated she was not aware Resident #1, Resident #2, Resident #3 and Resident #4 did not have hot water in their restrooms. The Housekeeping Supervisor stated before the Maintenance Director was terminated there was no hot water in those residents' rooms, but the Interim Maintenance Director had come to the facility to fix the overflowing water heater and said it had repaired the issue with the hot water. The Housekeeping Supervisor stated the Maintenance Director had been terminated about a year ago and she did not recall with the Interim Maintenance Director started assisting with maintenance concerns at the facility. The Housekeeping Supervisor stated that risk to the residents of not having hot water in their restrooms was the inability to properly wash off germs and bacteria and could also have affected their comfort at the facility. The Housekeeping Supervisor stated she was not aware of the hanging electrical cord and outlet in Resident #3's room and would let the Interim Maintenance Director know. A telephone interview with the Interim Maintenance Director on 8/18/26 at 11:05 a.m. revealed he was helping with maintenance issues at the facility one day per week until a Maintenance Director was hired. The Interim Maintenance Director stated he was at the facility last Wednesday (8/12/26) and had fixed the oven in the kitchen. The Interim Maintenance Director stated he had been informed of the toilet leak but had not gotten a chance to fix it, as he had concentrated on the issues with the oven. The Interim Maintenance Director stated he was planning on going to the facility 8/19/26 to fix the toilet and any other important issues they were having. The Interim Maintenance Director stated he would become aware of issues needing maintenance through orders staff put on the door or text messages he received from the staff. The Interim Maintenance Director was not aware of the hot water issues in Resident #1, Resident #2, Resident #3 and Resident #4's restroom and stated he had not checked restroom sink temperatures because he was only at the facility once per week and had more important issues to fix. The Interim Maintenance Director stated a toilet leaking in the restroom could affect the residents because they could slip and fall and their toilet may not be working properly. The Interim Maintenance Director stated hot water in resident restrooms and should be between 90 and 105 degrees Fahrenheit and was unable to state what the hot water temperature was in restroom sinks of any residents. The Interim Maintenance Director stated he had not been informed about the hole in the wall, the electrical cords and outlet hanging in Resident #3's room or the broken baseboards in Resident #3 and Resident #4's restroom. The Interim Maintenance Director stated he was unable to state how the cords affected the resident because he did not know where they were at or what kind of cords they were but stated it along with the broken baseboards would affect the appearance of the residents' rooms/restrooms and the rooms/restrooms would look messy and incomplete. The Interim Maintenance Director stated residents' not having hot water in their restroom sinks could have affected their ability to properly wash their hands. The Interim Maintenance Director stated he had been assigned to help once per week sometime in January or February of 2026. An interview with CNA C on 8/18/26 at 1:27 p.m. revealed Resident #1's neighbor had frequently complained about the broken toilet and sink and the Interim Maintenance Director would fix it but they kept on having issues, so they eventually moved him to another room and shortly after that Resident #1' neighbor was discharged from the facility. CNA C stated there had been no hot water in Resident #1, Resident #2, Resident #3 and Resident #4's restroom in over 3 months. CNA C stated she had reported the no hot water to the Administrator and Housekeeping Supervisor. CNA C stated the facility did not have a maintenance person, but they had someone that came once per week. CNA C stated the maintenance person had not come to the facility for about 2 weeks. CNA C stated the risk to the residents of having a broken toilet and dirty restroom was they could have gotten an infection, fallen, or gotten sick. The risk of not having hot water in their room would be a lack of care to the residents and unsanitary conditions. An interview with LVN D on 8/18/26at 1:45 p.m. revealed she was aware of the conditions of Resident #1's toilet and had sent a picture of it to the Housekeeping Supervisor when she came on shift that morning. LVN D stated Resident #1 had told her he had heard people in the bathroom at night and it sounded like they were dumping something in the toilet. LVN D stated she was unsure of who was going into the restroom and dirtying it. LVN D stated she was aware Resident #1, Resident #2, Resident #3 and Resident #4 had no hot water in their sink and had not had hot water since April of 2026. LVN D stated she consistently reported the issue with the hot water in the restrooms since April of 2026 to the Administrator. LVN D stated they moved Resident #3's roommate last week to another room because his bed was in front of the hole with the electrical wires sticking out and every time, he moved his bed up or down the wires would come pop out of the hole. LVN D stated maintenance had repaired the hole and wires several times since she started in April of 2026. LVN D stated maintenance had not been to the building since they moved Resident #3's roommate out of the room and therefore had not fixed the hole and the wires. LVN D stated any time there was an issue with the environment they would write a maintenance order and would report it to the Administrator. LVN D stated the risk to the residents of broken and unclean toilets was infection control and just overall happiness with their home environment. LVN D stated the risk to the residents of no hot water in their sinks was issues with infection control and their inability to wash their faces comfortably with warm water. An interview with LVN E on 8/18/26 at 2:09 p.m. revealed the Maintenance Director was terminated in about March of 2026 and corporate was sending a maintenance person once per week to assist with repairs and maintenance of the building. LVN E stated she had not seen the Interim Maintenance Director at the facility for several weeks. LVN E stated the building overall had issues with hot water and she was aware that Resident #1, Resident #2, Resident #3 and Resident #4 did not have hot water in their restrooms. LVN E stated she had spoken to upper management about the hot water issues several times with the last time being in the last week. LVN E stated the hole and electrical cords hanging in Resident #1's room was like that since about March of 2026. LVN E stated the baseboards in Resident #3 and Resident #4's shared restroom had been messed up for a long time. LVN E stated the risk to the residents of having dirty toilets, holes in the walls and no hot water was they could have gotten infections, and their sense of dignity could have been affected. An interview with the Administrator on 8/18/26 at 2:28 p.m. revealed she had been the administrator at the facility for 2.5 months and there had been no Maintenance Director. The Administrator stated Corporate had told her they were working on hiring a Maintenance Director. The Administrator was unsure how long the facility had no Maintenance Director. The Administrator stated the Interim Maintenance Director was responsible for all the repairs and upkeep of the building. The Administrator stated The Interim Maintenance Director typically came once per week and she would provide him with the list of necessary repairs prior so he would know what he needed to bring to repair the items on the list. The Administrator stated she did not have anyone who could temp the water from the sinks in Resident #1, Resident #2, Resident #3 and Resident #4's restrooms and was unaware the residents had no hot water. The Administrator stated she was also not aware of the hole and hanging electrical cords in Resident #3's room. The Administrator stated she had just been made aware of the dirty toilet in Resident #1's room and had Housekeeping clean it. The Administrator stated the expectation was all resident rooms and restrooms, including rooms with no residents, should be cleaned daily. The Administrator stated maintenance issues should have been reported on the maintenance request sheets and placed on the Maintenance Director's office door. The Administrator stated that when the Interim Maintenance Director came to the facility, he should have been checking the door and completing the maintenance orders. The Administrator stated the risk to the residents of not having hot water in their bathrooms was the quality of their hand washing or them reducing the likelihood they washed their hands. The Administrator stated the hot water temperature should be at the regulatory requirement to ensure safety of the residents, but she was unable to state what the temperature of water should have been. The water should be at temperature it is a regulatory requirement. The Administrator stated the risk to the residents of the unrepaired baseboards and hanging electrical cords was residents' quality of life and their right to a homelike environment. Record review of the facility's policy Department Work Hours, Maintenance revised May 2008 reflected .Maintenance service is provided seven (7) days per week, sixteen (16) hours per day. Record review of the facility's policy Maintenance Service revised December 2009 reflected Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, andguidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 8. The Maintenance Director is responsible for maintaining the following records/ reports. a. Inspection of building; b. Work order requests. Record review of the facility's policy Work Orders, Maintenance revised April 2010 reflected Maintenance work orders shall be completed in order to establish a priority of maintenance service.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #1) reviewed for care plans in that:The facility failed to include interventions for ADLs in Resident #1's care plan.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Record review of Resident #1's face sheet dated 04/28/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Unspecified Sequelae of Cerebral Infarction (unspecified neurological deficits or functional impairments remaining after a stroke), Flaccid Hemiplegia Affecting Left Dominant Side (sudden, complete paralysis and loss of muscle tone on the left side), Other Cerebral Infarction (disrupted blood flow to the brain), Paraplegia (paralysis affecting the lower half of the body) and Epilepsy (a brain condition that causes recurring seizures). Record review of Resident #1's quarterly MDS assessment, dated 03/30/2026, reflected a BIMS score of 13, which indicated intact cognitive response. Section GG0130-Functional Abilities revealed substantial/maximal assistance for lower body dressing and putting on/taking off footwear, partial/moderate assistance for upper body dressing, shower/bathe self, and toileting hygiene. Section GG0130 also revealed Resident #1 required set up or clean-up assistance for oral hygiene and eating, and supervision for personal hygiene.Record review of Resident #1's Comprehensive Care Plan reviewed 04/28/2026 failed to address ADLs as a focus of care.During an interview on 04/28/26 at 3:05 p.m., the MDS Coordinator stated MDS was responsible for care plans. She stated ADLs were not included in Resident #1's care plan because she worked remotely and had internet issues. She stated Resident #1's care plan should have been updated after the MDS assessment March 30, 2026. She stated all ADLS's included in the MDS assessment, such as dressing, bathing, toileting, and hygiene, should have been included in the care plan. She stated ADLs included in the care plan were important for the quality of care for residents.During an interview on 04/29/26 at 11:33 a.m., the Corporate Social Worker stated IDT, comprised of nursing, dietary, the therapy director, the MDS Coordinator and Social Worker, met weekly. She stated MDS, considered a part of nursing, was responsible for the implementation of the care plan. She stated ADLs were important to guide staff on what the residents' care needs were. She stated she didn't know why Resident #1's care plan lacked ADL goals and interventions.During an interview on 04/28/26 at 2:34 p.m., the Administrator stated the MDS Coordinator and DON were responsible for the care plan. He stated ADLs, such as hygiene and showers, were important in the care plan because staff needed to know what to do to care for residents and to ensure residents received the care needed. He stated CNAs were hindered without ADLs in the care plan and when the nurse informed them what each resident required.During an interview on 04/29/26 at 10:12 a.m., CNA A stated she was unaware of ADL care, goals, and interventions contained in Resident #1's care plan. She stated she doesn't have access to the POC system that contained it. She stated she figured out Resident #1's ADL care related to hygiene, showers, and incontinent care and Resident #1 told her how the care was done.During an interview on 04/29/26 at 10:38 a.m., CNA B stated she wasn't aware of ADL care plan goals and interventions for Resident #1 since she didn't have access to POC, but she asked the charge nurse. She stated that ADLs in the care plan were important to know what duties were performed and what residents could/could not do. Review of the facility policy titled Comprehensive Care Plans, revised 09/04/24, revealed on page 1, The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #1) reviewed for personal hygiene.The facility failed to provide Resident #1 with scheduled showers between 03/24/2026 and 04/28/2026.This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.Record review of Resident #1's face sheet, dated 04/28/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Unspecified Sequelae of Cerebral Infarction (unspecified neurological deficits or functional impairments remaining after a stroke), Flaccid Hemiplegia Affecting Left Dominant Side (sudden, complete paralysis and loss of muscle tone on the left side), Other Cerebral Infarction (disrupted blood flow to the brain), Paraplegia (paralysis affecting the lower half of the body) and Epilepsy (a brain condition that causes recurring seizures). Record review of Resident #1's quarterly MDS assessment, dated 03/30/2026, reflected a BIMS score of 13, which indicated intact cognitive response. Section GG0130-Functional Abilities revealed partial/moderate assistance (helper does less than half the effort) for showering/bathing.Record review of Resident #1's Comprehensive Care Plan reviewed 04/28/2026 failed to address ADLs as a focus of care.Record review of Resident #1's tasks in the electronic health record did not reflect the residents assigned shower days. Further review of the posted Resident Shower Sheet revealed Resident #1's scheduled shower days were Tuesday, Thursday, Saturday from 6am-6pm.Record review of completed shower sheets revealed Resident #1 was showered 03/28/2026, 04/14/2026, and 04/22/2026.During an interview on 04/28/2026 at 1:08 p.m., Resident #1 revealed she was showered three-four times since arriving at the facility. Resident #1 stated she couldn't remember the last shower. Resident #1 stated she had an odor and could smell herself. Resident #1 was observed neatly dressed; an odor was not observed.During an interview on 04/28/26 at 12:16 p.m., the Administrator revealed the expectation was for residents to shower when they wanted or on their scheduled shower days. The Administrator stated showers and refusals were documented on shower sheets since there wasn't access to the POC system. He stated nurses were responsible for checking daily to ensure residents were showered. He stated showers were important for hygiene and resident rights.During an interview on 04/29/26 at 10:12 a.m., CNA A stated Resident #1 was showered or received bed baths, but she didn't remember when. She stated she failed to document the shower sheets. She stated she didn't have access to the electronic medical record system for documenting ADL care for showers. She stated the risk of unbathed residents included hygiene or skin issues.During an interview on 04/29/26 at 10:38 a.m., CNA B stated she showered Resident #1 once since her admission. She stated CNA A normally showered Resident #1. She stated showers, refusals, and bed baths were documented on the shower sheets. She stated she didn't have POC access for documentation of ADL care. She stated residents were at risk for skin breakdown, smells, odors, and uncleanliness when unbathed.During an interview on 04/29/26 at 1:56 p.m., LVN A stated charge nurses were responsible for overseeing CNAs to ensure residents were showered by checking with the CNA and residents. She said she was too busy with her assigned duties to check if/when residents were showered. She stated shower sheets were kept in the shower sheet book and documented in the POC computer system. She stated showers/bathing were important for hygiene, it helped residents feel better, and it helped residents' skin.Record review of facility policy, dated reviewed 02/11/22, titled, Resident Showers, reflected, Residents will be provided showers as per request or as per shower schedule.

Based on interview and record review the facility failed to promptly notify the ordering physician regarding laboratory results outside of clinical reference range for 1 of 3 residents (Resident #1) reviewed for laboratory services. The facility did not ensure the physician was promptly notified when Resident #1's urinalysis results completed on 01/29/26 indicated a urinary tract infection, resulting in a delay in treatment until 02/04/26. This failure could place residents at risk of not receiving lab services as ordered and not providing timely treatment.Findings included: Record review of Resident #1's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old female with an admission date of 09/27/24. Resident #1 had a BIMS score of 15, which indicated she was cognitively intact. She required partial to moderate assistance with activities of daily living, was occasionally incontinent of bladder and frequently incontinent of bowel. Diagnoses included heart failure, dementia and chronic obstructive pulmonary disease (lung diseases that make it hard to breath by restricting air flow). Record review of Resident #1's physician's verbal orders dated 01/27/26, reflected, UA with C&S if indicated one time only. written by LVN C. Record review of Resident #1's Urinalysis lab report completed on 01/29/26, reflected, Urine Nitrates- Positive- (usually indicate a urinary tract infection) .Urine WBC- too many to count (indicate the immune system is fighting infection or inflammation in the urinary tract) . Record review of Resident #1's Physician order summary report dated 02/10/2026 reflected, Macrobid oral capsule 100 mg (antibiotic used to treat uncomplicated urinary tract infections) Give 1 capsule by mouth two times a day for UTI for 10 days.start date 02/04/26. In an interview with Resident #1 on 02/10/26 at 8:30 a.m. she stated she was finally feeling a little better. She stated it took the facility forever to treat her urinary tract infection. She said she told the staff she was having burning on urination and knew she had a urinary tract infection. She stated LVN C brought her a specimen cup, but stated she could not remember the exact date. She stated after they took the specimen it took 5-6 days to get any medication. She stated the urinary burning had stopped. She stated she was still taking the medication the doctor ordered for her. In an interview with LVN A on 02/10/26 at 2:20 p.m. she stated she was the primary charge nurse on the 6 a.m. to 2 p.m. shift. She stated the process they had in place when labs were ordered was they place it on the 24-hour report for follow up. She stated when they received the lab results they review it and either text the MD with the results or faxed it to the physician's office. She stated she notified the physician on 02/03/26 by text message. She stated she was not sure why the MD was not notified sooner. She stated that was the week of the ice storm and stated the MD's office was closed during that time. In an interview with LVN B on 02/10/26 at 2:35 p.m. she stated she worked the 10 p.m. to 6 a.m. shift. She stated any time they have outstanding labs she checks the electronic record to see if the lab results have been uploaded. She stated if they had been uploaded, she prints off the results and places them in the physician's binder for the day shift to call the MD with results. She stated she was pretty sure she had printed off the lab report for Resident #1 on 01/29/26. She stated she was not sure why the MD was not notified the next day. In an interview with LVN C on 02/10/26 at 2:45 p.m. she stated had worked from 10 p.m. to 6 a.m. on the weekend of 01/31/26. She stated she stayed at the facility that weekend due to the icy weather. She stated she saw Resident #1's lab results and stated there was nothing in the progress notes or on the 24-hour report indicating the MD had been notified. She stated she faxed the lab results to his office. She stated she placed the lab results back in physician's review book. In an interview with Resident #1's MD on 02/10/26 at 3:35 p.m. he stated his expectation for the facility staff was to contact him by phone for any abnormal lab results. He stated he could not recall getting a call from the facility. He stated the concern for not getting notified could result in a delay in treatment. He stated he did not feel the delay caused a significant problem and stated they had started Resident #1 on an antibiotic. During an interview on 02/10/26 at 4:30 p.m., the DON stated she expected the charge nurse who received the lab results to notify the physician in a timely manner of all abnormal labs. She stated they needed to document the notification in the progress notes, so the oncoming staff were aware the notification had been made and note any new orders if any were given. The DON stated she thought the physician was reviewing the labs through the electronic medical records but stated she was not 100% sure if he or his Nurse Practitioner had remote access. She stated she was going to have to set up a better process to monitor labs and ensure they were following up and notifying the MD. She stated she had already started in-servicing the nurses on the protocol and expectations. She stated a delay in treatment for any infection could result in a more severe infection which could require an unnecessary hospitalization. During an interview on 02/10/26 at 4:45 p.m., the Administrator stated he expected the physician to be notified in a timely manner of labs. The Administrator stated the DON was responsible for overseeing and monitoring labs. Record review of the facility's undated policy titled Lab and Diagnostic Test Results-Clinical Protocol reflected, . When test results are reported to the facility, a nurse will first review the results.A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition.A physician can be notified by phone, fax.another person acting as the physician's agent.Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress notes section of the medical record and not on the lab results report.Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for three of four quarters for 2025 (Quarters 1, 2, and 3) reviewed for sufficient nursing staff.Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for three of four quarters for 2025 (Quarters 1, 2, and 3) reviewed for sufficient nursing staff. The facility did not have sufficient staff according to the PBJ report for fiscal year 2024, Quarter 3 (04/01/24-06/30/24), and fiscal year 2025 Quarter 1 (10/31/24-12/31/24), and Quarter 2 (01/01/25-03/31/25). This failure could place residents at risk of diminished quality of life and quality of care. Findings included: Record review of the CMS PBJ report for fiscal year 2024 Quarter 3 (04/01/24-06/30/24) indicated: the facility failed to have Licensed Nursing Coverage 24 hours a day on: 04/19 (Friday); 04/22 (Monday); 04/23 (Tuesday); 04/25 (Thursday); 04/26 (Friday); 05/06 (Monday); 05/19 (Sunday); 05/27 (Monday) . Record review of time sheets for LVN hours reflected the following:04/19 (Friday): 14.38 LVN hours04/22 (Monday): no hours to provide04/23 (Tuesday): 10.58 hrs 04/25 (Thursday): 12.42 hrs04/26 (Friday): 8.02 hrs05/06 (Monday): 12.72 hrs05/19 (Sunday): 14.43 hrs05/27 (Monday): 23.07 hrs Record review of the CMS PBJ report for fiscal year 2025 Quarter 1 (10/31/24-12/31/24) indicated: the facility triggered for one star staffing, excessively low weekend staffing, and failed to have Licensed Nursing Coverage 24 hours a day on: 11/17 (Sunday); 11/28 (Thursday), 12/01 (Sunday); 12/07 (Saturday); 12/08 (Sunday); 12/25 (Wednesday). Record review of LVN hours timesheets reflected the following:11/17 (Sunday): no hours11/28 (Thursday): 23.26 hrs12/01 (Sunday): 15.18 hrs12/07 (Saturday): 16.12 hrs12/08 (Sunday): 15.93 hrs12/25 (Wednesday): 22.95 hrs Record review of the CMS PBJ report for fiscal year 2025 Quarter 2 (01/01/25-03/31/25) indicated: the facility triggered for one star staffing, excessively low weekend staffing, and failed to have Licensed Nursing Coverage 24 hours a day on: 01/01 (Wednesday); 01/04 (Saturday); 01/05 (Sunday); 01/11 (Saturday); 01/19 (Sunday); 02/01 (Saturday); 02/02 (Sunday); 02/08 (Saturday); 02/17 (Monday); 03/02 (Sunday). Record review of LVN hours timesheets reflected the following:01/01 (Wednesday): 24 hour coverage 01/04 (Saturday): 16.10 hrs 01/05 (Sunday): 24 hour coverage 01/11 (Saturday): 14.90 hrs 01/19 (Sunday): 15 hrs02/01 (Saturday): 15.15 hrs 02/02 (Sunday): no hours 02/08 (Saturday): 8.27 hrs02/17 (Monday): 8.63 hrs03/02 (Sunday): 9.65 hrs In an interview on 07/02/25 at 4:35 PM with the Administrator she stated she had worked at the facility for about a year and she and the DON were responsible for scheduling LVN coverage. She stated the DON was hired on May 26, 2025. She stated it was important to have a LVN coverage 24 hours a day to ensure residents received care. She stated staff call-outs happened more often than she wanted, and staff were supposed to find coverage if they were not able to come to work. She stated that the facility used agency nursing to supplement and there was never a time where a licensed nurse was not on site. In an interview on 07/02/25 at 5:47 PM with the DON she stated she was responsible for scheduling LVN coverage, and her hire date was May 26, 2025. She the facility had placed ads on different platforms, staff were hired and then they did not show up for work or just do not return. She stated she expected staff to follow the schedule and find coverage if they were not able to come in to work. She stated when an LVN or aide did not show up for their shift, she covered it and worked on the floor. She stated it was important to have 24/7 LVN coverage to ensure residents received medication and care. Record review of the facility's policy titled Staffing, Sufficient and Competent Nursing, dated 2001, reflected: .Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services

Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 28 days out of 365 days reviewed.Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 28 days out of 365 days reviewed. The facility failed to have an RN for 8 consecutive hours 7 days a week for 28 days out of 365 days reviewed from April 1, 2024 through March 31, 2025. These failures could place all residents at risk for their clinical needs not being met. Findings included: Record review of the CMS PBJ report for fiscal year 2024 Quarter 3 (04/01/24-06/30/24) reflected no RN hours for the following dates: 05/04 (Saturday); 05/05 (Sunday); 05/11 (Saturday); 05/12 (Sunday); 05/18 (Saturday); 05/19 (Sunday); 05/25 (Saturday); 05/26 (Sunday); 06/01 (Saturday); 06/02 (Sunday); 06/08 (Saturday); 06/09 (Sunday); 06/15 (Saturday); 06/16 (Sunday) . Record review of the CMS PBJ report for fiscal year 2025 Quarter 1 (10/1/24-12/31/24) reflected no RN hours for the following dates: 10/06 (Sunday); 11/02 (S); 11/03 (Sunday); 11/17 (Sunday); 12/07 (Saturday) Record review of the CMS PBJ report fiscal year 2025 Quarter 2 (01/01/25-03/31/25) indicated: the facility triggered for one star staffing, excessively low weekend staffing, and no RN hours on: 01/04 (Saturday), 01/05 (Sunday), 01/11 (Saturday), 02/01 (Saturday), 02/02 (Sunday), 02/08 (Saturday), 02/09 (Sunday), 02/15 (Saturday), 02/1 (Sunday), 03/02 (Sunday). In an email to the Administrator, dated 07/01/25 at 10:53 AM RN hours were requested for the following dates: 01/04 (Saturday), 01/05 (Sunday), 01/11 (Saturday), 02/01 (Saturday), 02/02 (Sunday), 02/08 (Saturday), 02/09 (Sunday), 02/15 (Saturday), 02/16 (Sunday), 03/02 (Sunday). In a reply email, dated 07/01/25 at 11:36 AM, the Administrator replied: No RN hours recorded for the specified dates. In an email to the Administrator, dated 07/01/25 at 2:35 PM RN hours were requested for the following dates:05/04 (Saturday); 05/05 (Sunday); 05/11 (Saturday); 05/12 (Sunday); 05/18 (Saturday); 05/19 (Sunday); 05/25 (Saturday); 05/26 (Sunday); 06/01 (Saturday); 06/02 (Sunday); 06/08 (Saturday); 06/09 (Sunday); 06/15 (Saturday); 06/16 (Sunday); 10/06 (Sunday); 11/02 (S); 11/03 (Sunday); 11/17 (Sunday); 12/07 (Saturday). In a reply email, dated 07/01/25 at 2:52 PM, the Administrator replied: NO RN hours for the dates requested to report. In an interview on 07/02/25 at 4:35 PM with the Administrator she stated the DON covered the RN hours on the weekdays and she was not able to provide time sheets for RN hours because the DON was salaried and recently started in May 2025. She stated RN coverage had been spotty on the weekends, the facility had gone through 2 different RNs for double weekends. She stated there was an RN who worked from February to June of 2024 and had a lot of call outs. She stated that the facility advertised the positions on different platforms. She stated there were no residents who had missed services or treatment because an RN was not onsite. She stated that staff contacted her, the DON, the physician or nurse practitioner depending on the situation. She stated the corporation also had RNs at other facilities she could call with any questions. She stated it was important to have a RN coverage 8 hours a day to ensure residents received care. She stated RN coverage was important because RNs were trained more extensively and were a resource for LVNs . In an interview on 07/02/25 at 5:47 PM with the DON she stated she was responsible for scheduling RN coverage and currently covered the required 8 hours for the facility and over the weekend was at the facility on Saturdays and was always available via phone. She stated they were interviewing a candidate for an RN weekend supervisor at the end of the week. She stated it was important to have a RN coverage because they were more skilled than an LVN and were able to assess patients differently. Record review of the facility's policy titled Staffing, Sufficient and Competent Nursing, dated 2001, reflected: .3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed annual assessment. Based on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed annual assessment. The facility did not have a completed Facility Assessment. This deficient practice could affect all residents and contribute to insufficient staffing and a lack of necessary resources to provide necessary care to residents. The findings were: During the entrance conference on 06/30/25 at 9:46 AM the Administrator was provided the Entrance Conference Checklist which instructed the facility to provide the survey team the facility's Facility Assessment within 4 hours of the entrance. In an interview on 07/02/25 at 4:35 PM with the Administrator, she confirmed they did not have a facility assessment. Record review of the facility's census, dated 06/30/25, reflected the census was 25. Record review of the facility's policy titled, Facility Assessment, dated October 2018, reflected: A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. 1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents.

Based on observation, interview, and record review the facility failed to provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 reviewed for resident council meeting.Based on observation, interview, and record review the facility failed to provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 resident groups reviewed for resident council meeting. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns [NAME] to lack of privacy. Findings included: In an interview during the confidential group interview on 06/30/25 at 12:20 PM revealed monthly resident council meetings were held in the facility's dining room due to the facility renovations. Observation and interview on 06/30/25 at 3 PM during a confidential resident group meeting with 6 residents revealed the resident council meetings were held in the dining room. The dining room was located at the front entrance where visitors and staff entered the facility. The residents stated that they would prefer to meet in a private room so that residents felt comfortable to speak freely about their concerns without worry that staff overhead. They stated they were told there was not a room that had enough space to accommodate the residents. In an interview on 07/02/25 at 11:07 AM with the Activity Director she stated the residents did not meet in an ideal place due to the facility remodel because the residents did not all fit in a room. She stated privacy for resident council meetings was important because when residents' had complaints or needed to speak freely, and they might not speak up if they thought staff were listening. She stated that residents had the right to a private meeting in their own home to improve their stay at the facility. She stated that she did not bring up her concerns of the resident's lack of privacy because she was aware the remodel was occurring. Record review of resident council minutes for June 2025, May 2025, and April 2025 revealed no location and concerns addressed included dietary and laundry concerns. In an interview on 07/02/25 at 4:35 PM with the Administrator she stated resident council meetings had been taking place in the dining room to accommodate all the residents and staff tried to stay in their offices or out of the area for at least a half an hour when council meetings occurred. She stated that resident council meetings were supposed to be private so the residents did not feel like things they said were going to come back at them, especially if they were discussing a specific employee. She stated she planned to speak with the Activity Director and move the resident council meetings into a different room. Record review of the facility's policy for resident council, titled Resident Council, dated February 2021, reflected: The facility supports residents' rights to organize and participate in the resident council.1.The purpose of the resident council is to provide a forum for:a. residents, families and resident representatives to have input in the operation of the facility;b. discussion of concerns and suggestions for improvement;c. consensus building and communication between residents and facility staff; andd. disseminating information and gathering feedback from interested residents.3. The resident council group is provided with space, privacy and support to conduct meetings.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #3 and Resident #16) of 3 residents reviewed for infection control. Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #3 and Resident #16) of 3 residents reviewed for infection control. The facility failed to ensure LVN B disinfected the blood pressure cuff in between blood pressure checks for Residents #3 and #16. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Observation on 07/01/25 at 8:59 AM revealed LVN B performing morning medication pass, during which time she checked the blood pressure on Resident #3. LVN B did not sanitize the blood pressure cuff before and after using it on Resident #3 and continued to the next resident without sanitizing the blood pressure cuff. LVN B then checked Resident #16's blood pressure. LVN B did not sanitize the blood pressure cuff before using it on Resident #16. Interview on 07/01/25 at 9:35 AM, LVN B stated reusable equipment, like blood pressure cuffs, should be sanitized before and after use on each resident to keep germs from spreading. She stated she was nervous and forgot to sanitize the blood pressure cuff between residents' use. In an interview with the DON on 07/02/25 at 05:51 PM, She stated her expectation staff to sanitize blood pressure cuff after each use. She stated to ensure staff were knowledgeable in the sanitation of blood pressure cuff the facility would do skills competency checks and she stated she would make daily rounds and watched care and medication administration. On 07/02/25 at 4:15 PM requested facility's policy, not provided.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #2 and Resident #24) of 6 residents reviewed for ADLs. Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #2 and Resident #24) of 6 residents reviewed for ADLs. The facility failed to ensure: - Resident #2 had her fingernails cleaned and trimmed on 6/30/25. - Resident #24 had her fingernails trimmed 6/30/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (group of thinking and social symptoms that interferes with daily functioning), and cerebral infarction (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death). Resident #2's BIMS score of 3, which indicated Resident #2' cognition was severely impaired. The MDS assessment indicated Resident #2 required maximal assistance with personal hygiene. Record review of Resident #2's Care Plan revised 05/15/25, reflected the following: Problem: [Resident#2] has an ADL self-care performance deficit . Goal: [Resident #2] will improve current level of function in through the review date . Interventions: . Personal hygiene . The resident requires maximal to total one person with personal hygiene and oral care . In an observation on 06/30/25 at 10:53 AM revealed Resident #2 was lying in her bed. The nails on both hands were approximately 0.3cm in length extending from the tips of her fingers. The nails were discolored tan and had brownish colored residue underside and on the nail beds. The nails on the right index and middle finger were chipped. Resident #2 was unable to answer questions. Record review of Resident #24's Quarterly MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hemiplegia (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), cognitive communication deficit, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Resident #24's BIMS score of 12, which indicated Resident #24 was cognitively intact. The MDS assessment indicated Resident #24 required supervision with personal hygiene. Record review of Resident #24's Care Plan dated 06/12/24, reflected the following: Problem: [Resident #24] has an ADL selfcare performance deficit . Goal: [Resident #24] will maintain current level of function . Interventions Toilet use: The resident requires partial assistance of one staff participation to use toilet, . Personal hygiene/oral care: I require assistance from staff with hygiene care at times, Level of assistance may vary depending on my condition. In an observation and interview on 06/30/25 at 11:04 AM revealed Resident #24 was sitting on her bed. The nails on both hands were approximately 0.7cm in length extending from the tip of her fingers. The nails were curved and not shaped. Resident #24 stated she did not like her nails that long. Resident # 24 stated staff were busy to do her nails. In an interview on 06/30/25 at 11:14 AM, CNA A stated CNAs and nurses were responsible to clean and cut the residents' nails. CNA A stated did not notice Resident #2's and Resident # 24's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an Interview on 07/02/25 at 5:51 PM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. Interview with the DON revealed she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADONs would do the routine rounds to monitor. The DON stated residents having long and dirty nails could be an infection control issue and skin break down if scratching. - Record review of the facility's policy Fingernails/Toenails Care dated February 2018, reflected the following: . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #22) of one resident reviewed for catheter care.Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #22) of one resident reviewed for catheter care. The facility failed to ensure Resident #22 had a physician's order for a Foley catheter on 06/30/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections. Findings included: 1.Record review of Resident #22's quarterly MDS assessment, dated 06/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her BIMs score was 11 indicating her cognitive status was moderately impaired. Her diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (group of thinking and social symptoms that interferes with daily functioning), and cognitive communication deficit. The resident required maximal assist for toileting hygiene. MDS assessment reflected resident did not have an indwelling Foley Catheter. Review of Resident #22's care plans dated 6/30/25 reflected she did not have a care plan for an indwelling Foley catheter or care of the Foley. Record review of Resident #'22's physician's orders dated 6/30/25 and medical diagnosis revealed that the resident did not have a diagnosis or order for a Foley catheter. An observation and interview on 06/30/25 at 10:29 AM of Resident #22 revealed the resident had a Foley catheter that was off the floor and covered with a bag. Resident #22 stated she could not urinate last week and that was why she had the catheter. In an interview with LVN D on 07/01/25 at 03:21 PM stated 2 days ago resident did not urinate for the day and the hospice nurse was in the facility. LVN D stated the hospice nurse asked her to insert a Foley catheter. LVN D stated she should not insert or replace a Foley catheter without a physician order. She stated the Foley catheter was supposed to have an order for insertion, an order for daily care, an order for the size, and an order for change. In an interview with the DON 07/02/25 at 05:51 AM she stated a nurse was not allowed to insert or replace a Foley catheter without a doctor's order. She stated a Foley catheter order came in a form of a group of orders which included an order for the size of the catheter, an order for insertion, an order for monitoring the output of urine, an order to change periodically and as needed. The DON stated the catheter should be care planned to guide the resident care of the foley catheter. The DON stated she would educate nurses on catheter orders. Review of the facility policy, Urinary Tract Infection (Catheter - Associated revised September 2017, reflected: . Insert catheters only for indications deemed appropriate for urinary catheter insertion, and as ordered .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (Women's Hall Medication Cart and Men's Hall Medication Cart) of 3 carts reviewed for pharmacy services. The facility failed to ensure:- the Men's Hall Medication Cart did not have 1 insulin pen for Resident #22 with an expired open date and 1 insulin pen for Resident #10 with an expired open date. - LVN E responsible for Women's Hall Medication Cart, counted controlled drugs every shift change. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications and could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: - Record review and observation on [DATE] at 11:22 AM of the Men's Hall Medication Cart, with LVN B revealed the pen of insulin Novolog 100 unit/ml for Resident #22 with an open date of [DATE]. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. The pen of insulin Lantus 100 unit/ml for Resident #10 with an open date of [DATE]. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. Interview on [DATE] at 12:53 PM, LVN B stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. She stated the nurse supposed to label the pen with the open date when first opened it. LVN B stated the purpose of putting an open date was for expiration purposes because the insulin was only good for 28 days. She stated after 28 days the insulin would be ineffective. - Record review and observation on [DATE] at 11:28 AM of Women's Hall Medication Cart, with LVN B revealed missing signatures for On duty for [DATE] (2:00 PM to 10:00 PM shift) and [DATE] (10:00 PM to 6:00 AM shift) of the narcotic count sheet. Interview on [DATE] at 3:57 PM, LVN E stated she should have signed the narcotic sheet after counting the narcotics, on [DATE] and on [DATE] at the beginning and at the end of the shift. She stated she got busy with a resident asking for medication and did not go back to sign the count sheet. She stated she knew that she supposed to sign immediately after the count was done. She stated the risk would be potential for drug diversion. Interview on [DATE] at 5:51 PM, the DON stated the insulin flex pens and vial, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and she stated she would do random checks of the medication carts for monitoring. The DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated she would randomly check the carts for monitoring. On [DATE] at 4:15 PM requested facility's policy to the Administrator, not provided. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (Women's Hall Medication Cart and Men's Hall Medication Cart) of 3 carts reviewed for pharmacy services. The facility failed to ensure:- the Men's Hall Medication Cart did not have 1 insulin pen for Resident #22 with an expired open date and 1 insulin pen for Resident #10 with an expired open date. - LVN E responsible for Women's Hall Medication Cart, counted controlled drugs every shift change. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications and could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: - Record review and observation on [DATE] at 11:22 AM of the Men's Hall Medication Cart, with LVN B revealed the pen of insulin Novolog 100 unit/ml for Resident #22 with an open date of [DATE]. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. The pen of insulin Lantus 100 unit/ml for Resident #10 with an open date of [DATE]. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. Interview on [DATE] at 12:53 PM, LVN B stated nurses were responsible to check the medication carts and the insulin pens for the open dates before giving insulin. She stated the nurse supposed to label the pen with the open date when first opened it. LVN B stated the purpose of putting an open date was for expiration purposes because the insulin was only good for 28 days. She stated after 28 days the insulin would be ineffective. - Record review and observation on [DATE] at 11:28 AM of Women's Hall Medication Cart, with LVN B revealed missing signatures for On duty for [DATE] (2:00 PM to 10:00 PM shift) and [DATE] (10:00 PM to 6:00 AM shift) of the narcotic count sheet. Interview on [DATE] at 3:57 PM, LVN E stated she should have signed the narcotic sheet after counting the narcotics, on [DATE] and on [DATE] at the beginning and at the end of the shift. She stated she got busy with a resident asking for medication and did not go back to sign the count sheet. She stated she knew that she supposed to sign immediately after the count was done. She stated the risk would be potential for drug diversion. Interview on [DATE] at 5:51 PM, the DON stated the insulin flex pens and vial, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and she stated she would do random checks of the medication carts for monitoring. The DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated she would randomly check the carts for monitoring. On [DATE] at 4:15 PM requested facility's policy to the Administrator, not provided.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen.Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date 11 bags of broccoli stored in the original packages in the freezer. This failure could place residents who at risk for food-borne illness and food contamination. Findings included: Observation in facility's kitchen on 06/30/25 at 09:30 AM revealed 11 bags of frozen broccoli in the original packages in the walk-in freezer were not dated. In an interview on 06/30/25 at 9:30 AM with the Dietary Manager, she stated all food items needed to be labeled with the date received and they must have been missed. She stated she and the cooks were responsible for labeling food when it was delivered. She stated it was important to label food with the date received so they knew when food goes bad. Record review of facility policy titled Food Receiving and Storage, dated October 2017, reflected: Foods shall be received and stored in a manner that complies with safe food handling practices.8. All foods stored in the refrigerator or freezer will be covered, labeled and dated.

Based on observation, interview and record review, the facility failed to provide a safe environment for residents, staff, and the public for one (oxygen room) of one oxygen room and one (CNA room) of one CNA room observed for oxygen storage safety. The facility failed to securely store oxygen cylinders in the facility's only oxygen room and only CNA room on 06/06/25. These failures could affect the residents by placing them at risk of injury due to oxygen cylinders becoming unsecured and becoming a hazard. Findings included: Observation on 06/06/25 at 7:33 AM revealed one free-standing oxygen cylinder without a rack, chain, or strap in the corner of the CNA room by the door. Observation and interview on 06/06/25 at 7:35 AM with LVN A revealed the oxygen cylinder in the CNA room was unsecured. LVN A stated the oxygen cylinder should be secured in a rack. LVN A stated it was a safety risk for them to be unsecured. Observation and interview on 06/06/25 at 10:40 AM with the ADM revealed four free-standing oxygen cylinders without a rack, chain, or strap in the oxygen room. The ADM stated she did not know why the oxygen cylinders were not in the rack since there was room in the rack for them. The ADM stated the oxygen cylinder should be secured with a rack, bag or strap to prevent them from falling over since they were combustible. Interview on 06/09/25 at 9:08 AM with the ADM revealed the facility did not have a policy on oxygen storage. Review of National Fire Protective Association, (NFPA) 99, 2012 Edition, Section 11.6.2.3, reflected: .(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart .

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of two (Resident #1) residents reviewed for elopement: The facility failed to prevent Resident #1's elopement through a window in an unoccupied room on [DATE] which resulted in resident being found two houses from the facility and facility staff being unaware that he had eloped. These failures resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no harm with a scope identified as isolated. These failures negatively affected the residents and placed all residents at risk of injury or harm by not having a safe and secure facility. Findings included: Review of Resident #1's face sheet reflects that resident was a [AGE] year-old man admitted on [DATE] with a diagnosis of epilepsy, dementia, lack of coordination, sequelae of cerebral infarction, dysphagia, dysarthria, hypertension, heart failure, bipolar disorder, depression, hemiplegia and hemiparesis, hyperlipidemia, and hyponatremia. Records review reflect that Resident #1 was deceased [DATE] and discharged from the facility. Records review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] reflected that resident's Brief Interview for Mental Status (BIMS) score was 12 meaning the resident was cognitively intact. Section GG0170 (Mobile Devices) reflects that resident used a wheelchair for mobilizing. Records review of Resident #1's elopement risk assessment dated [DATE] reflected a score of 12, categorized as a high risk to wander. The comments/notes reflected Resident #1 has verbally stated he wanted to leave. Review of Resident #1's care plan, initiated on [DATE], reflected a focus area for dementia and elopement risk. Review revealed the resident was at risk for wandering/elopement related to a history at previous facility and dementia diagnosis. The interventions were to identify pattern of wandering: was wandering purposeful, aimless, or escapist, was resident looking for something, does it indicate the need for more exercise, and intervene as appropriate. Records review of Resident #1's progress notes reflected a behavior note dated [DATE], stating that the resident got agitated during morning smoke break when only allowed one cigarette per smoke break and stated well, I am going to start walking the highway. Resident then forcefully got out of the smoking area door and forced staff to give him his second cigarette and not following commands or redirections. Records review of the Provider Investigation Report dated [DATE] reflected at 5:00 pm during routine rounds by the CNA E, Resident #1 was not in his room and his wheelchair was inside his room. The resident eloped and staff found the resident walking on the side of the road behind the building approximately 2 houses down. The resident reported he climbed out the window in room [ROOM NUMBER] trying to go to his Family Member's house. The report further read the resident was assessed at 6:00pm and there was a minor scratch on his knee from climbing out the window. Review of the World Weather website reflected that the temperature on [DATE], the date of Resident #1's elopement, reflects that the high was 55 degrees Fahrenheit and the humidity 81%. During an interview on [DATE] at 10:18am, the Administrator revealed Resident #1 expressed he wanted to visit his family member when he was found. The Administrator stated Resident #1 did not exhibit elopement or exit seeking tendencies prior to the incident. The Administrator stated Resident #1 wandered in/out of rooms prior to the incident but not the facility. The Administrator stated elopement interventions were not put in place prior because Resident #1 was content when staff contacted his Family Member whenever he expressed, he wanted to see him. The Administrator stated the police were not contacted during the elopement incident because Resident #1 was missing for only 5 minutes. The Administrator stated the risk of elopement could be injury, death, or traffic challenges. The Administrator stated there was no reason why elopement drills were not conducted after the incident. The Administrator revealed details of resident elopement risk assessments were not made known to her. An interview and observation on [DATE] at 10:40 am with the Maintenance Director revealed Resident #1 was in room [ROOM NUMBER] separated by a shared bathroom with room [ROOM NUMBER]. There was no resident in room [ROOM NUMBER] at the date and time of elopement. Observation of room [ROOM NUMBER] revealed a locked window and a screen. Observation of Resident #2's room revealed a missing window screen. The Maintenance Director stated there are 8 windows without screens and he stated he was unsure if screens were ordered by the owners. During an interview on [DATE] at 8:16 am, CNA E stated she last saw Resident #1 at 4:30pm after the smoke break. CNA E stated Resident #1 was not in his room when she attempted to give him his dinner tray. CNA E stated she asked LVN I if she had seen the resident and when she had not, they searched for the resident. CNA E stated she noticed Resident #1's wheelchair in front of the window in the adjoining unoccupied room next to his room, separated by the bathroom. CNA E stated the window was closed and the screen was out. CNA E stated LVN I exited the back door and found Resident #1 at the end of the driveway. CNA E stated Resident #1 was asked where he was going, and he replied to his Family Member house. During an interview [DATE] at 3:58pm, LVN J stated Resident #1 expressed he wanted to go home and pointed his finger and stated, it's right over there. LVN J stated she was informed Resident #1 wandered by taking the screen out of the window and climbed out. During an interview [DATE] at 9:29am, CNA F stated she worked the day of the incident and stated Resident #1 was not in the dining room nor in his room when CNA E attempted to pass the dinner tray. CNA F stated CNA E and LVN I searched the facility for Resident #1. CNA F stated LVN I found resident #1 outside. CNA F stated she was not in-serviced on any topic after the incident. Records review of in-services on abuse and neglect and elopement dated [DATE], reflected the absence of CNA F's signature for participation. Review of the facility provided policy on Wandering and Elopements revised [DATE] reflected If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .If a resident is missing, initiate the elopement/missing resident emergency procedure. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement official, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). Review of the facility-provided policy on Abuse Prevention - Identifying Neglect dated [DATE] reflected that Circumstances that can lead to neglect include failure to monitor or supervise residents. The Administrator was notified on [DATE] at 2:50 pm that an Immediate Jeopardy situation had been identified due to above failures. The IJ template for plan of removal was given to the facility on [DATE] at 2:50 pm. The facility's plan of removal was accepted on [DATE] at 11:09 AM. The accepted plan of removal for the Immediate Jeopardy included the following: Plan: 1. Identified Resident #1 is no longer at facility . 2. Resident #2 is at risk for elopement and has the potential to be affected by the alleged deficient practice. At this time, she is not currently exit seeking as of [DATE]. 3. The one and only resident deemed an elopement risk has interventions in place that include room next to nurses' station, when she is up in her wheelchair, she is at the nurse's station or in the dining room at mealtimes, any other times she is within eyesight of a staff member. The MDS Coordinator or designee will update the care plan as needed for elopement interventions with a completion of [DATE]. MDS Coordinator will be in-serviced by Administrator to update care plans as needed appropriate with a completion date of [DATE]. 4. Administrator will in-service and re-educate staff on elopement and abuse and neglect with a follow up posttest starting on [DATE] with a completion on [DATE]. Any remaining staff members will not be allowed back to work until they complete the in-service and posttest. 5. Elopement drill will be done by DON or designee and will be done on each shift and completed by [DATE]. The DON (upon her return) and the designee who are conducting the elopement drills will be in-serviced by the Administrator regarding the proper procedures of the drill. The elopement drill does list all individuals who are supposed to be notified of an elopement. Any remaining staff will not be allowed back to work until they complete elopement training. 6. Administrator has been in-serviced on correct elopement protocol, including notifying the police, by [NAME] President on [DATE]. 7. Maintenance Manager will buy 10 new screens to put on the rooms completed by [DATE]. On any unoccupied rooms where screens are missing those doors will remain closed as well as the jack and [NAME] bathrooms until the screens can be replaced by [DATE]. All doors will stay closed on any unoccupied rooms as well as the jack and [NAME] bathrooms. 8. Maintenance Manager will be in-serviced by Administrator on checking window screen to ensure proper screen placement with a completion date of [DATE]. The Survey Team monitored the current plan of removal as follows: Review of the facility's inservice initiated on [DATE] revealed staff were inserviced on elopement and given posttests. Record review of inservice sheet dated [DATE] revealed the Administrator was inserviced on elopement protocols, including notifying the police. Record reviews of elopement drills revealed the Administrator conducted elopement drills on [DATE] at 10:00pm and [DATE] at 10:02 am. Record review of the inservice sheet dated [DATE] revealed the Administrator inserviced the Maintenance Director checking proper screen placement. Observation on [DATE] at 12:00PM revealed all windows had screens. Observation revealed doors for unoccupied resident rooms were closed. Interviews were conducted with staff from 12:00pm-4:30PM on [DATE]. Interview with the Administrator revealed she was inserviced on elopement protocols, including notification of the police. The Administrator stated she conducted elopement drills and inservices on elopement and proper screen placement. Interview with the Maintenance Director revealed the Administrator inserviced him on proper screen placement. The Maintenance Director stated he placed screens on the windows. Interviews with CNA A, CNA B, CNA C, and CNA D, LVN E, LVN F, LVN G, LVN H, LVN K and RN I revealed the staff were inserviced on elopement and safety precautions. Staff were able to describe elopements, what they would do in the event of a missing resident, and administration was able to describe the system for preventing and handling missing residents and to notify police department in the event of a missing resident. On [DATE] at 4:30 PM, the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of no harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on observation and interview, the facility failed to post the Health and Human Services Commission (HHHSC) complaint number and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of a state or federal regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of property for 1 of 7 mandatory postings. The facility failed on 05/14/2025 to ensure the required posting (signage) of a HHSC complaint number and statement about how a resident may file a complaint with the State Survey agency. This failure placed residents at risk of being unaware of who and how to contact the State Survey Agency and their right to file a complaint with the State Service Agency concerning any suspected violation of state or federal regulation. The findings included: An observation throughout the facility on 05/14/25 at 10:40 AM, revealed there was no HHSC complaint number and statement that the residents may file a complaint with the State Survey Agency posted in any location of the facility. In an interview with the Administrator on 05/14/25 at 10:48 AM, who stated the postings was not posted in the facility. Administrator stated she did not pay attention to what was posted on the walls. She stated she did not know why there was no HHSC complaint number and statement that the resident may file a complaint with the State Survey Agency posted in the facility. Administrator stated it was important to have this signage posted so residents will know how to file a complaint regarding staff. The Administrator said the risk to the residents would be unreported abuse and neglect.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-center plan that includes services that are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one of twenty-eight ( Resident #2) reviewed for care plans. The facility failed to update Resident #2's care plan to reflect elopement risk. These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of Resident #2's face sheet reflected that the resident was a [AGE] year-old woman admitted on [DATE] with diagnoses of fracture of unspecified part of neck of right femur, type 2 diabetes, cerebral infarction, hyperlipidemia, spinal stenosis, dementia, anxiety disorder, glaucoma, anemia, hypertension, and rheumatoid arthritis. Records review of Resident #2's annual Minimum Data Set assessment dated [DATE] reflected that resident's Brief Interview for Mental Status (BIMS) score was 3 meaning the resident was severely cognitively impaired. Section G (Functional Status) for Activities of Daily Living Assistance reflected that Resident #2 required extensive assistance resident involved in activity, staff provide weight-bearing support, two+ person physical assist. Records review of Resident #2's care plan dated 04/25/2025 reflected no care plan for elopement. Records review of Resident #2's elopement risk assessment dated [DATE] reflected a score of 14, categorized as a high risk to wander. Review of a progress note entered on 5/12/2025 at 5:00 (am or pm not specified) reflected that Resident #2 stated she had to leave soon and go home and was going through drawers in her room gathering her belongings. Observation of Resident # 2 on 05/13/25 at 5:30 PM revealed resident was sitting in the dining room in a wheelchair. The surveyor attempted interview with DON about care plans on 05/14/25 at 9:27am. The DON's voicemail box was full and unable to leave a message. The DON did not call back by the date and time of exit on 05/16/25 at 4:30pm Interview with the MDS Coordinator on 05/15/25 at 10:11 am revealed Resident # 2 did not have a care plan for elopement. Review of the facility provided policy on Wandering and Elopements revised March 2019 reflected If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 1 resident whose care plan was reviewed, in that: The facility failed to develop a comprehensive care plan for Resident #1. This failure could place residents at risk of receiving inadequate individualized care and services. Findings included: Review of Resident #1's admission MDS assessment dated [DATE] reflected Resident#1 was admitted to the facility on [DATE] with diagnoses of dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), diabetes mellitus (elevated blood sugar), and heart failure. Resident#1 had a BIMS score of 12 indicating he was moderately cognitively intact. Review of Resident #1's care plan revealed no care plan was in the system (PCC) for Resident#1 as of 04/10/25. Interview on 04/10/25 at 11:35 AM with the DON, she stated Resident#1 should have a care plan since he was admitted on [DATE]. She stated she will check the PCC, after checking the PCC, the DON stated there was no care plan for Resident#1. Interview on 04/10/25 at 12:22 PM over the phone with the MDS coordinator, she stated Resident#1 care plan was done on 3/04/2025, and it was in the system (PCC). The MDS coordinator further stated she does not know what happened and she thought it was deleted. She stated all residents must have a care plan to make sure their needs were meet. Follow up interview on 04/10/25 at 12:29 PM with the DON, she stated the MDS coordinator was responsible for uploading the resident care plans, and she as a DON does the intervention. She stated the care plan was needed so the appropriate services and care are provided to the residents. Review of facility's policy titled, Care Planning-Interdisciplinary Team with a revised date of September 2013 revealed Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive Care plan for each resident . 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #2) of 1 resident reviewed for ADL's. The facility failed to ensure Resident#2 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident#2 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including muscles weakness, dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and hypertension (High blood pressure). He had a BIMS score of 06/15 indicating severe cognitive impairment. He was total dependent with personal ADLs. Record review of Resident #2's Comprehensive Care Plan last revised 04/10/25 reflected the following Focus. Resident #2 has and ADL self-care performance deficit r/t dementia, Goal. The resident#2 will maintain current level of function through next review. Intervention. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . Observation/Interview on 04/10/25 at 07:57 AM revealed Resident#2 was lying in bed. Resident#2 had long fingernail approximately 0.7 cm on both hands, with clear brown matter underneath. Resident#2 was asked if he want his fingernail trimmed and cleaned, he replied yes. Interview on 04/10/25 at 08:35 AM with CNA A, CNA A looked at Resident#2 fingernail and stated they were long and some of them were dirty underneath. CNA A stated Resident#2 fingernails needed to be cleaned and trimmed. CNA A further stated the risk to the residents they could scratch them self, and development of infection. Interview on 04/10/25 at 09:50 AM with LVN B, she stated both CNAs and charge nurses in the Halls were responsible for residents' nail care. She stated if a resident had diabetes, only nurses were allowed to trim resident's nails. She stated the risk for not performing nailcare was increased risk of infection and skin break down. Interview on 04/10/25 at 11:35 AM with the DON, she stated her expectation was that nail care should be provided every shower day and as needed. She stated that both CNAs and charge nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had diagnosis of diabetes. The DON stated residents who had dirty fingernails could be an infection control issue. Record Review of the facility policy titled Nail Care-Fingernails and Toenails, revised September 13, reflected, Purpose: 1. To promote cleanliness 2. To prevent injury 3. To prevent infection The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 1 Resident (Resident#1) reviewed for pharmacy services. The facility failed to ensure Resident#1 did not have his morning medications (Allopurinol, Aspirin, Glimepiride, Isosorbide, metoprolol, Nifedipine, Plavix, Potassium, Torsemide, Calcium Carbonate -Vit D with min, and Gabapentin) left on the bedside table on 04/10/25. These failures could place residents at risk of medication misuse, not receiving physician ordered medications which could result in non-therapeutic treatments or injuries. Findings Included: Record review of Resident # 1's face sheet dated 04/10/25 reflected a [AGE] year-old male with an admitted [DATE]. Diagnoses included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) diabetes mellitus (elevated blood sugar), and heart failure. Record review of Resident #1's Physician orders summary sheet dated 04/10/25 reflected, Allopurinol oral tablet 300 mg Give 1 tablet by mouth in the morning; Aspirin oral tablet 81 mg Give 1 tablet by mouth in the morning; Glimepiride oral tablet 4 mg Give 1 tablet by mouth in the morning; Isosorbide oral tablet 60 mg Give 1 tablet by mouth in the morning; Metoprolol oral tablet 50 mg Give 1 tablet by mouth in the morning; Nifedipine oral tablet 30 mg Give 1 tablet by mouth in the morning; Plavix oral tablet 75 mg Give 1 tablet by mouth in the morning; Potassium oral tablet 10 mEq Give 1 tablet by mouth in the morning; Torsemide oral tablet 20 mg Give 1 tablet by mouth in the morning; Calcium Carbonate -vit D-Min Oral Tablet 600-200 mg-unit Give 1 tablet by mouth in the morning; Gabapentin oral tablet 300 mg Give 1 tablet by mouth in the morning. With a start date of 02/25/25. In an observation and interview on 04/10/25 at 07:44 AM revealed Resident#1 sitting up in bed, alone in his room. A medication cup with his name full of medications tablets in different forms and colors (11 in total) was observed on the bedside table. Resident #1 stated the nurse left the medications for him to take. He stated he will take his medications. In an observation/interview with LVN B on 04/10/25 at 07:49 a.m. she looked at the medications cup and told Resident#1, that he needed to take his medication. She stated she gave the medications to Resident#1 this morning and had to go to open the facility door and forgot to come back and check on the resident to see if he took his medications. She stated the risk to resident was that he could miss his morning medication if another resident walked to the room and took the medication. She stated the unattended medications could cause harm to another resident if he/she took them. In an interview on 04/10/25 at 11:35 AM with the DON she stated the resident medications should not be left unattended, or at the bed side table. She stated the nurses were training to give resident their medications, and make sure the resident swallow the medications before the nurse leave the room. The DON stated the unattended medications could cause harm to Resident#1 if he missed his morning dose and could harm another resident if he/she took the medication and was allergic to any one of them. Record review of the facility policy Medication Labeling and Storage, revised February 2023, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .